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Patients
What is Visual Impairment?
What is Visual Acuity?
Your Spectacle Prescription Explained
What Is Low Vision Rehabilitation?
Finding Low Vision Rehabilitation Services
A Self-Help Guide to Non-Visual Skills
Maintaining independence and quality of life
Vision Loss and Mental Wellness
State Vision Screening and Standards for License to Drive
GuideMe Custom Patient Guides
Clinical Trials
A.S.P.E.C.T. Patient Engagement Program
Low Vision Resource Directories
Assistive Technology Products
Financial Assistance
Suppliers of Low Vision Devices
Transportation Services Directory
U.S. Agencies, Centers, Organizations and Societies
Publications
Latest News
Caregivers
Who are Caregivers
The Caregiver’s “Needs Pyramid”
The Caregiver’s Low Vision T.A.S.K. Force
The ABCs of Caring for the Visually Impaired
Resources for Caregivers
Healthcare Professionals
Resources for Eyecare Professionals
A Low Vision Rehabilitation Delivery Model
Form
Output
Diabetic Retinopathy
0 of 21 completed
1: Do you live in the United States?
Yes
No
2: Do you live alone?
Yes
No
3: Are you employed full or part time?
Yes
No
4: Are you currently a student?
Yes
No
5: Is there someone whom you consider to be your caregiver?
Yes
No
6: Are you an active member of a support group, church, retirement community or other opportunity to be with others?
Yes
No
7: How are you doing financially?
Please select...
Okay
Need Assistance
8: What is your current transportation status?
Please select...
Driving
Not driving and have no available transportation
Not driving, but have available transportation
9: How often do you engage in activities outside of the home (traveling, volunteering, participating in or attending events, etc.)?
Please select...
Less than 2 hours a week
Up to 5 hours a week
More than 5 hours a week
11: What kind of diabetic retinopathy do you have? (This is very important, so if you aren’t sure, please call your clinic.)
Please select...
Nonproliferative
Proliferative
12: Do you also have diabetic macular edema?
Yes
No
13: Is your condition bilateral (both eyes) or unilateral (one eye)?
Please select...
Bilateral
Unilateral
14: Do you wear either prescription glasses or contacts?
Yes
No
15: How is the vision in your best affected eye with lens correction?
Please select...
Good
Blurry and/or distorted vision
Dark or empty areas in your visual field
16: Are your eyes overly sensitive to glare and/or bright light? Yes No
Yes
No
18: Do you currently smoke tobacco?
Yes
No
19: Do you get at least 20 minutes of productive exercise every day?
Yes
No
20: Are you experiencing feelings of depression that you can’t seem to shake?
Yes
No
21: Are you age 65 or older?
Yes
No
22: Do you schedule comprehensive eye exams at least once a year?
Yes
No
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